NEUROLOGY OF ARKANSAS
PATIENT MEDICAL HISTORY
PATIENT NAME:_________________________________ AGE:_________ FAMILY DOCTOR: ________________________
PERSONAL HISTORY
Marital Status:
Children:
( ) Single
( ) Married
How Many: _________________
( ) Divorced
( ) Engaged
( ) Other
Ages: ___________________________________________________________
Highest Grade Completed in School: __________________________________________________________________________
Do you work: ______________
What kind of job: _____________________________________________________________
How did you learn of our clinic: ______________________________________________________________________________
GENERAL INFORMATION
Why were you referred to see Dr. McCoy? (Please be specific)
________________________________________________________________________________________________________
Have you ever had any of the following? (check if yes)
Where
When
CT scan of the brain / spine
_______
_______________________________________
____________
MRI scan of the brain / back/ neck
_______
_______________________________________
____________
Carotid Doppler / Echocardiogram
_______
_______________________________________
____________
Neck / back x-rays
_______
_______________________________________
____________
Physical Therapy
_______
_______________________________________
____________
Have you ever seen other physicians regarding your current symptoms:
Please give physicians name below:
When
Neurologist
_____________________________________________________
____________
Chiropractor
_____________________________________________________
____________
Cardiologist
_____________________________________________________
____________
Psychologist, Psychiatrist
_____________________________________________________
____________
Ear, nose and throat doctor
_____________________________________________________
____________
HABITS
Please circle yes or no and fill in the blanks:
Are you a smoker?
Yes
No
How much? __________________________
How long? _____________
Do you drink alcohol
Yes
No
How much? __________________________
How much? _____________
Do you smoke marijuana?
Yes
No
How often? _____________________________________________________
Do you use other illicit drugs?
Yes
No
What kind? ___________________________
Do you drink caffeinated beverages
Yes
No
How many cups or glasses per day? __________________________________
How often? _____________
ARE YOU ALLERGIC TO ANY MEDICATIONS? (if so please list) ________________________________________________
MEDICAL HISTORY
Do you have or have you had any of the following?
____ Asthma
____ Diabetes
____ Hepatitis
____ Sleep Difficulty
____ Emphysema
____ Hypoglycemia (low blood sugar)
____ Seizures
____ Jaw/Joint Pain
____ Glaucoma
____ Back Trouble
____ Fainting/ Blacking out
____ Other (list)_
____ Heart Disease
____ Neck Trouble
____ Arthritis
____________________
____ Irregular Heart Beat
____ Thyroid Disease
____ Nervous Condition/ Anxiety
____________________
____ High Blood Pressure
____ Liver Disease
____ Depression
____________________
____ Stomach Ulcers
____ Renal (Kidney) Disease
____ Cancer
____________________
____ Hiatal Hernia
____ Exposure to AIDS
____ Sinus Problems
____________________
____ Cancer, if so what kind: __________________________________________________________________________________
____ Autoimmune Disorders, such as Lupus, Rheumatoid Arthritis, etc. ________________________________________________
____ Family History of: Stroke, Parkinson’s, Alzheimers, ALS (Lou Gherig’s disease), other nerve or muscle disorders
resulting in full or partial paralysis. (circle all that apply)
SURGICAL HISTORY
Please list all surgeries with the most recent first:
Type of operation
Approximate date
Hospital
Surgeon
___________________________
_____________
____________________
__________________________
___________________________
_____________
____________________
__________________________
___________________________
_____________
____________________
__________________________
___________________________
_____________
____________________
__________________________
Please list all medications (List prescription medications first, then any over-the-counter medications. Bring Meds or complete list)
Medication
Dosage
How Often
What for
Prescribed by
________________________
____________
___________________
___________________
_____________________
________________________
____________
___________________
___________________
_____________________
________________________
____________
___________________
___________________
_____________________
________________________
____________
___________________
___________________
_____________________
________________________
____________
___________________
___________________
_____________________
REVIEW OF SYSTEMS
Constitutional:
How many hours do you sleep at night? ____________________
Yes
No
Do you experience excessive daytime sleepiness?
Yes
No
Change in appetite?
Yes
No
Do you snore?
Yes
No
Recent weight gain / loss in the last 6 months?
Yes
No
Are you physically fatigued?
Yes
No
Do you experience fever or chills?
Yes
No
Chest palpitations?
CV:
Yes
No
Chest pain?
Yes
No
Passing out spells?
HEENT:
Yes
No
Do you have frequent headaches?
Yes
No
Trouble swallowing?
Yes
No
Flashing lights. Dark spot in vision?
Yes
No
Trouble with speech?
Yes
No
Hallucinations?
Yes
No
Double or loss of vision?
Yes
No
Hearing loss?
Yes
No
Dry eyes or dry mouth?
Yes
No
Ringing / roaring in ears?
Yes
No
Frequent mouth ulcerations?
Yes
No
Dizziness?
Yes
No
Neck pain or stiffness?
RESP:
Yes
No
Shortness of breath at rest or exertion?
Yes
No
Chronic cough?
Yes
No
Pain on inhalation?
Yes
No
Cough up blood?
Yea
No
Shortness of breath after lying flat?
Yes
No
Awaken gasping for air?
GI:
Yes
No
Abdominal pain?
Yes
No
Diarrhea or constipation?
Yes
No
Nausea or vomiting?
Yes
No
Blood with stool?
Yes
No
Black blood bowel movements?
GU:
Yes
No
Urinary incontinence?
Yes
No
Bowel incontinence?
Yes
No
Burning or painful urination?
Yes
No
Frequent urination?
Yes
No
Blood in urine?
Yes
No
Kidney stone?
Yes
No
Abnormal sweating?
ENDOCRINE:
Yes
No
Sexual dysfunction?
Yes
No
Light-headedness with standing?
PSYCH:
Yes
No
Depression?
Yes
No
recent stress in life?
Yes
No
Anxiety?
Yes
No
Suicidal / Homicidal thoughts?
NEUROLOGIC:
Yes
No
Numbness or tingling in extremities?
Yes
No
Confusion-spells?
Yes
No
Extremity weakness?
Yes
No
Seizures?
Yes
No
Paralysis?
Yes
No
Memory loss?
Yes
No
Imbalance when walking?
Yes
No
In-coordination of arms?
Yes
No
Burning or stinging pain in extremities?
Yes
No
Slurred speech?
Yes
No
Involuntary movements?
Yes
No
Tremors?
Yes
No
Low back pain?